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FOR OFFICE USE: <br /> ` t <br /> APPLICATION 10OR SANITATION PERMIT <br /> � - - Permit No. - - ---------- -- <br /> (Complete to Triplicate) <br /> ----------------------------------- <br /> Date Issued <br /> -----------------------_--------------------_--------- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San'-Joaquin Local Health District for a permit to construct and install the work herein <br /> ..s. <br /> described. This application is made incomplianceywith County Ordinance No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATION `--_---_V!.... --_CENSUS TRACT -------------- <br /> Owner's Name -------------- - Phane -. <br /> Address ------------ ---------- - ----- ------- --- City <br /> A <br /> Contractor's Name ----- -- - --- --`-�---------- icennse # ---------- ------------ Phone ��1 T/ 4 <br /> Installation will serve: Residence'❑Apartment House[]:Commercial :MTrail er-Court-!H-�---•, <br /> Motels(]Other j1 --------- <br /> Number of living units:__________ Number.of.bedroo s ._._:___Garb ge Grin r .VU_ Lot Size, _.._.�J__��_--.._______._.._____.__ <br /> -- u' � <br /> Water Supply: Public System and name -------------- ----- - - Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ r lay ],.. .Pe it ❑R Sand Loam [] Clay Loam "❑ <br /> . .(.L. a»L <br /> Hardpan ❑ Adobe Fill Material _____________If yes, type ---------- <br /> -------------- <br /> (Plot plan, showing size of lot, location of system in relation.�to..wel,ls,-buildings,-.etc. must be pi ce on reverse side.) <br /> NEW INSTALLATION: ,(No septic tank or"Idpage pit permitted if pubfiF sewer is available-within 200 feet,) N <br /> I <br /> r � Y / 1 <br /> TREATMENT I ] Sf DTIC TANK ] .4 I ize..._..----_ X�b----------- ----------- Liquid Depth __ -------------- <br /> PACKAGE` T e _ Material__C_11 No. Compartments --------- ------------ <br /> &pacity' <br /> --- YP I 0 <br /> .94' � � I p I <br /> Distance to nearest: Well, ------------------------------------Foundation _--�---- --- Prop. Line .- -- ----•---- <br /> % <br /> -------------- Length,of of each line-------�'� ___ -.-- Total Length ------ ------------ <br /> t LEACHING LINE [ ) No. of Cines_ _____ .. iyyi <br /> f 'D' Box ----�, y"Type�""Filter Materiaf`__A�_ -----Depth Filtero Material -------1t?------------------------------ <br /> . Distance to nearest: Well -- -------------------- Foundation ---1-Q--- ----------- Property Line ------,�.----------- <br /> - SEEPAGE PIT [ ] Depth -----2�------ Diameter 1,_. --.�-,Number--.------r------ ---------- Rock Fillied Yes No <br /> f Water Table D6pth --------------------------------------- ------Rock Size . - <br /> �- , <br /> z Distance to nearest:'Well --------------------------------------Foundation ---lfl../.._....... Prop. Line ---------------------- <br /> REPAIR/ADDITEON{Prev. Sanitation Perm't#`__'__________________________________ Date -.-._____._____.._________________) <br /> Septic Tank (Specify Requirements) { <br /> " :, _ ti-=------------------------•------ ---------------- <br /> j <br /> Disposal Field (Specify Requirements) ----------------------- <br /> --- ----- --------- f-- --------------------------------------------------------- ------------------------ <br /> ------------------------------------ -------- -------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordant a with San Joaquin <br /> Count Ordinances State Laws and +Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: g <br /> "I certify that in the performance of the work for which this permit isliss ued, I shall not employ any person in such manner <br /> g s Compensation laws of California." <br /> as to become subject to Workmas <br /> � - � Owner <br /> -------- <br /> ---- Title `, <br /> wne <br /> (If other a or) � j- <br /> IFOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - - -------------------------------------------- ---. DATE ---- ------------------ <br /> BUILDINGPERMIT ISSUED .--_------------------------_-------------------------------------------------------------- ----------------DATE ------------- --------------------------- <br /> ADDITIONAaL COMMENTS '__--- --- --- ----- <br /> =�� -------------- <br /> ---------- ____ ________ <br /> -- - - ----------- - ----- ------ - - <br /> __ _ �- ----------------- <br /> ----- - --- - --- -- - -------------- - - --------------------------------------------------- -------------- <br /> Final Inspection by -------------- -------- Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />